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<br />WHEN THIS COPYCARRES TIE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTE14 /T CERTFES TFE BELOW TO BE A TRUE COPY OF THE ORIGINAL REC- 0007.0M ME4WTH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTI S-Satift SIGH lS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />6 o 2 3 Ao
<br />�1 r, rJ 2? u `� 0 0 5 0 3 ASSISTa srdo�Tis -rR -=
<br />17 LINCOLN, NEBRASKA HEALTH AND HUMAN SER1llCES SYSTE'Uf 7
<br />STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERMCWfMP p SUFNMRT
<br />VITAL STATISTICS = -- --
<br />CERTIFICATF, OF DF.ATN - --
<br />`A /
<br />Lot Seven (7), South Platte Township, Amick Acres Third Subdivision, Hall County, Nebraska
<br />1. DECEDENT -NAME FIRST MIDDLE LAST ��
<br />2 SEX
<br />3 DATE OF DEATH /Month Day Year/
<br />Beulah Esther Freeman
<br />Female
<br />January 18, 2000
<br />4. CITY AND STATE OF BIRTH IlNror in USA.. name Country/
<br />5a. AGE - Last Birthday
<br />UNDER 1 YEAR
<br />UNDER 1 DAY
<br />15, DATE OF BIRTH /Month. Day. Yeaq
<br />MOS 1 DAYS
<br />5c. HOURS' MINS
<br />Doniphan, Nebraska
<br />(Yrs.l 73 Sb.
<br />Dec. 22, 1926
<br />7. SOCIAL SECURTIY NUMBER
<br />8a PLACE OF DEATH
<br />506 --30 -4577
<br />HOSPITAL ❑ Inpatient OTHER: ® Nursing Home
<br />❑ ER Outpatient ❑ Residence
<br />fib. FACILITY - Name /Ir not institution, give street and number
<br />St. Francis Memorial Health Care
<br />❑ DOA ❑ Other,Spec,ty,
<br />8c. CITY. TOWN OR LOCATION OF DEATH
<br />8d. INSIDE CITY LIMITS
<br />Be. COUNTY OF DEATH
<br />Grand Island
<br />Yes ® Nci ❑
<br />Hall
<br />ga. SIDENCE - PATE
<br />9b. COUNTY
<br />9c. CITY, TOWN OR LOCATION
<br />9d. STREET AND NUMBER (Including Zip Coder
<br />9e. INSIDE CITY LIMITS
<br />Nebraska
<br />Hall
<br />Doniphan
<br />121 Monument Rd. 68832
<br />❑ In
<br />Yes No
<br />10. RACE - (e.g., White. Black. American Indian.
<br />11. ANCESTRY le. g.. Italian. Mexican. German, etc)
<br />12. ® MARRIED ❑ WIDOWED
<br />13. NAME OF SPOUSE pt wde. give maiden name)
<br />e1c.1(Specily)
<br />White
<br />(Speciryl
<br />American
<br />I
<br />NEVER DIVORCED
<br />MARFlIED El
<br />Roger M. Freeman
<br />14a USUAL OCCUPA71ON (Give kind o/ work done outing most 14b.
<br />KIND OF BUSINESS INDUSTRY
<br />15. EDUCATION (Spoi only highest grade completed)
<br />o/worbng even it etired)
<br />eacf%r
<br />Education
<br />Elementary or $eygndary (0 -12) College 1�-4 or 5 -I
<br />1G [�
<br />16 FATHER - NAME FIRST MIDDLE LAST 17.
<br />MOTHER FIRST MIDDLE MAIDEN SURNAME
<br />Noble George Hurst
<br />Pauline El.fleda. Rainforth
<br />18. WAS DECEASED EVER IN US. ARMED FORCES?
<br />19a. INFORMANT -NAME
<br />(Yes _rt d
<br />er M. Freeman
<br />19b. INFORVr NT MAILING AD (STREET OR R, F. D. NO.. CITY OR TOWN. STATE. ZIPI T
<br />21 Mo men Rd., Doniphan, NE 68832
<br />20. i;kl MCR- SIGNATlWEBLICE SE O.
<br />I7
<br />214.. METHOD OF DISPOS�TION�
<br />21b, DATE 21c.
<br />CEMETERYORCREMAT;IRY NAME
<br />Burial ❑Removal
<br />an - 21 / 2000
<br />Cedar View Cemetezy
<br />UN H ME • NA
<br />___
<br />21 d. CEMETERY OR CPEMATORY LOCATION CITY OR TOWN STATE
<br />Apfel- Butler- Geddes
<br />❑ Cremalion ❑ De ^a1,on
<br />Doniphan, Nebraska
<br />226. FUNERAL HOME ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
<br />1123 West Second, Grand Island, NE 68801
<br />23. IMMEDIAT RUSE (ENTER ONLY ONE CAUSE PER LINE FOR (al. Ibl. AND II Ime wee. 0115.1 an )eat
<br />PART (
<br />I�/y
<br />� /�� � ,�/� Q � \
<br />DUE TO, OR AS A CQNSEQUENCE OF Interval e n and deal
<br />DUE TO, OR AS A CONSEQUENCE OF Interval 0etween onset ann dram
<br />(cl I
<br />OTHER SIGNIFICANT CONDITIONS - Conditions contributing 10 the death but not related PART
<br />PART
<br />111 IF FEMALE, WAS THERE A 24. AUTOPSY
<br />25. WAS CASE REFERRED TO MEDICAL
<br />PREGNANCY
<br />IN THE PAST 3 MONTHS?
<br />EXAMINER OR CORONER'S
<br />II
<br />(Ages
<br />10 -541 Yes No Yes D No
<br />Yes Nc /�
<br />26.
<br />28b. DATE OF INJURY
<br />26c. HOUR OF INJURY
<br />28d. DESCRIBE HOW INJURY OCCURRED
<br />Accident Undetermined
<br />M
<br />Suicide Pending
<br />6e. INJURY AT WORK
<br />7161P�,ACJ, gF INJURY -Al hom , farm. street. facto
<br />factory
<br />ilding,
<br />26 LOCATION STREET OR R.F.D. NO. CITY OR TOWN STAT e
<br />9
<br />❑9
<br />Homi cide Invesogaovn
<br />❑ ❑
<br />Yes No
<br />ale /SP -dy,
<br />27a. DATE OF DEATH (Mo.. Day. YrJ
<br />28a. DATE SIGNED (Mo.. Day. Yr.)
<br />28b LIME OF DEATH
<br />"
<br />M
<br />N
<br />27b DATE SIGNED / .. Day Yr.)
<br />27c. TIME OF DEATH
<br />k „
<br />28c. PRONOUNCED DEAD IW... Day, YcJ
<br />_
<br />28d. PRONOUNCED DEAD /Ho-1
<br />20 du
<br />M�
<br />M
<br />x
<br />g
<br />27d. To the best of my knowle eat ce red at the ti ,date and place and due to the
<br />28e. On the basis of examination ardor investigation, in my opinion tlealn occurred at
<br />v
<br />cause(s) stated.
<br />n
<br />the time, date and place and due 10 the causels) slated.
<br />ISM nature and Title
<br />(Signature and Title
<br />DID TOBACCO USE CONTR THE DEATH? S ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b
<br />WAS CONSENT GRANTED?
<br />129.
<br />❑ YES ❑ NO NKNOWN ❑ YES _
<br />❑ YES NO
<br />31 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, CORD 'S PHYSICIAN OR COUNTY ATTORNEY( (Type or Printl
<br />Sitki M. Copur M.D. 2116 W. Faidley, Grand Island, NE 68803
<br />32a. REGISTRAR
<br />32b. DATE FILED BY REGISTRAR ( Mo.. Day. Vr.J
<br />JAN 24 2000
<br />`A /
<br />Lot Seven (7), South Platte Township, Amick Acres Third Subdivision, Hall County, Nebraska
<br />
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